Howdy friends! Over the course of this past year, I have tried to spend some time bridging the gap between allied health services (i.e Physical Therapy) and personal training. Today I want to cover a big one and how to handle exercise post heart surgery.

I strongly believe that personal trainers can be a huge key in getting people moving, but they need good quality resources to provide the best services. There are many different types of heart surgery and this guide is meant to concentrate on those types of procedures that typically occur in older patients.

These types of surgeries will also usually result in referrals to a Cardiac Rehabilitation program. Cardiac Rehab has four generally recognized phases. Phase 1 is acute and occurs while you are still in the hospital. The focus is pain management and easy mobilization. Phase 2 starts after discharge and usually takes place at a specialized facility as continuous monitoring during exercise is the main focus. Phase 2 usually lasts 4 to 8 weeks depending on the patient, the type of surgery, and progress made.

Phase 3 and 4 are short and long term maintenance phases. Many times, these occur at the patients’ own discretion. And while it’s a good thing to require less monitoring, it can also be a very scary undertaking. This is where a good personal trainer comes in. Understanding the basic types of surgeries and conditions and how to monitor these clients provides a huge boost to their confidence and adherence.

Types of Surgeries

Coronary Artery Bypass: This is the most common heart surgery. A blocked vessel around the heart is bypassed by a new vessel graft so that the heart can continue to receive oxygenated blood to pump.

Angioplasty: Usually an outpatient procedure where a catheter is guided to a blocked artery. A balloon on the end of the catheter is inflated to compress the blockage against the vessel walls and open the artery. Sometimes a stent is placed to keep the artery open.

Ablation: Another minimally invasive procedure that is used to correct arrhythmias by changing the conductive pathway across the heart muscle.

Pacemaker Placement: A surgery where an implantable device is placed to keep the electrical system of the heart firing when and how it should. Some pacemakers are always pacing or firing, others are used to sense arrhythmias and pace or shock the heart only if necessary.

Valvular or Aneurysm Repair: Surgery to repair any of the four valves of the heart, usually to repair congenital defects or sclerosis (hardening) of the tissues. Aneurysm repair is usually done to the pulmonary artery (from the heart to the lungs) or aortic artery (from the heart to the body) to correct bulges.

Many of these surgeries are done with robotics that allow for smaller incisions. But from a recovery standpoint, it is important to know if your client had a minimally invasive procedure or an open procedure. Obviously, if the procedure is open, there are going to be more limits on how strenuous exercise can be and especially on how much weight can be lifted by the upper body. Pain tolerance and management is also going to be critical in anyone with an open procedure.

Exercise Recommendations

Clients coming out of Phase 2 Cardiac Rehab will have paperwork and a decent knowledge of where their abilities are. This is a group that while it is good to push, it is also important to err on the side of caution. Meaning, push on days they come in well rested and feeling energized. The day they are tired or sluggish is not the day to challenge them.

The first thing you’ll need to do is get comfortable assessing heart rate and blood pressure. Every personal training office should have a blood pressure cuff. Learn how to use it confidently. Teach your client to monitor their own heart rate if they don’t know how. I am a huge fan of the 6-20 RPE scale as well. In a lot of these cases, clients are taking meds that might affect their heart rate response, so it’s good to get an RPE and track them both to learn their normal responses.

The second thing you need to do is understand what constitutes a full stop of exercise immediately. We call these absolute contraindications. These are things that need to be evaluated by their cardiologist before they exercise again. In other words we don’t mess around here: Blood clots in the past several weeks. Chest pain at rest, or that worsens without increases in workload. Arrythmias without cause and that causes dizziness or drops in blood pressure. Abnormal hemodynamic responses (i.e. huge spikes in blood pressure or drops in systolic blood pressure with increases in workload). Systemic infections (colds, flus, etc.).

Third, brush up on relative contraindications. These are things that don’t suggest a full stop of exercise but might give us clues about how well a client is feeling. If enough of these are present at onset, I always err on the side of caution. Either the session is skipped or I go very low level to see how the client responds. If one of these pops up during a session, the first response should be to slow down and monitor vital signs. If things don’t improve with a reduced workload, then stop exercise.

Relative contraindications include dizziness, lightheadedness, fainting in the previous 48 hours. Gray, ashen, or blue pallor, especially in the extremities. Shortness of breath, especially if it comes on suddenly or seems out of proportion to the workload.

By the time cardiac rehab patients get to personal trainers, they are typically cleared for all exercise. Obviously cardiologists want to see them focus on cardiovascular activities as it has a preventative and protective effect. Use their heart rate and RPE scores in combo to program this. If the client is physically able, walking is the best option. But stationary bikes are usually well tolerated, too.

For strength training, there is less research out there. I generally like to program a straightforward full body program to start off. If they love strength work or we see a lot of improvement, you can always adjust. Most cardiac patients do well alternating upper and lower body work, though. Additionally, full body work keeps the intensity low enough to increase their confidence.

Working with cardiac patients is an exercise (see what I did there?) in active listening and continuous symptom monitoring. Exercise is crucial for recovery and with a thoughtful trainer, most of these clients do very well.

If you read all the way to the end, you’re a real one! Until next time, be well friends!

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